Relaxation training in people with anxiety symptoms (in absence of depressive episode/disorder)

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Q4: Is relaxation training better (more effective than/as safe as) than treatment as usual in adults with anxiety symptoms

(in absence of depressive episode/disorder) - who are in distress or have some degree of impaired functioning?

Background Relaxation is one of the most common used techniques in the management of anxiety. Relaxation is a relatively simple form of psychological treatment and is thus of potential interest for non-specialized health care settings .

Population/Intervention(s)/Comparator/Outcome(s) (PICO)

Population: adults with anxiety symptoms

Interventions: relaxation training

Comparisons: treatment as usual

Outcomes: symptom reduction

adverse effects

List of the systematic reviews identified by the search process INCLUDED IN GRADE TABLES OR FOOTNOTES Manzoni GM et al (2008). Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC Psychiatry 8:41.

EXCLUDED FROM GRADE TABLES AND FOOTNOTES

Carlson CR, Hoyle RH. (1993) Efficacy of abbreviated progressive muscle relaxation training: a quantitative review of behavioral medicine research. Journal of

Consulting and Clinical Psychology, 61:1059-67. (Reason for excluding: old)

Relaxation training in people with anxiety symptoms (in absence of depressive episode/disorder)

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Eppley KR, Abrams AI, Shear J.(1989). Differential effects of relaxation techniques on trait anxiety: a meta-analysis. Journal of Clinical Psychology, 45:957-74.

(Reason for excluding: old)

Krisanaprakornkit T et al (2006). Meditation therapy for anxiety disorders. Cochrane Database of Systematic Reviews, (1):CD004998 (Reason for excluding:

meditation only. Meditation is likely a component of relaxation (and vice versa). Yet the Manzoni review covers relaxation more broadly).

Stetter F, Kupper S. (2002). Autogenic training: a meta-analysis of clinical outcome studies. Applied Psychophysiology, 27:45-98. (Reason for excluding:

audiogenic training only. Audiogenic training is a component of relaxation. Yet the Manzoni review covers relaxation more broadly)

PICO Table

Serial no.

Intervention/Comparison Outcomes Systematic reviews used for GRADE

Explanation

1 Relaxation/ usual care Symptom reduction; adverse effects

Manzoni et al (2008) review The Manzoni et al (2008) review is the only recent review that studies a broad, comprehensive range of relaxation techniques

Narrative description of the studies that went into the analysis

Manzoni et al (2008)describe the studies as follows: In 8 studies the sample was composed by people with physical diseases, in 6 studies by volunteers or

students, in 5 studies by patients with psychological or medically unexplained complaints. Progressive relaxation was used in 10 studies, the remainder

involved, autogenic training, applied relaxation or multi-method relaxation techniques. Out of 19 studies, 9 were North American publications, 5 were Asian, 3

European and 2 Oceanian. Ten studies involved individual sessions and nine studies involved group sessions. Comparison condition consisted of waitlist, simply

laying down on a relaxing chair or bed, and non-specific relaxing activities (i.e. reading a newspaper).

GRADE Tables

Table 1

Relaxation training in people with anxiety symptoms (in absence of depressive episode/disorder)

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Author(s): Mark van Ommeren and Scott Baker Date: 2009-06-27 Question: Should Relaxation vs treatment as usual be used for anxiety symptoms? Settings: Bibliography: Manzoni GM, Pagnini F, Castelnuovo G, Molirani E. Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC Psychiatry 2008, 8-41

Quality assessment

Summary of findings

Importance No of patients Effect

Quality No of

studies Design Limitations Inconsistency Indirectness Imprecision

Other

considerations Relaxation

treatment as

usual

Relative

(95% CI) Absolute

Anxiety symptom severity post intervention (Better indicated by higher values)

191 observational

studies2

serious3 no serious

inconsistency4,5

serious no serious

imprecision7

reporting bias8

5681 4371 - 0.51 higher (0.46 to 0.63 higher)9

VERY

LOW

CRITICAL

Safety

0 no evidence

available

none

0/0 (0%)

0/0 (0%) RR 0 (0 to

0)

0 fewer per 1000 (from 0 fewer

to 0 fewer) IMPORTANT

0% 0 fewer per 1000 (from 0 fewer

to 0 fewer) 1 See last paragraph of page 4 of the Manzoni et al, 2008 review

2 The 19 studies include a mix of observational studies and RCTs. The review does not indicate how many of each.

3 No information on drop-outs. Review only includes studies after 1997.

4 I-squared is 38% (calculated from Q(18) = 28.93).

5 See first column page 6 of the Manzoni et al, 2008 review.

6 The comparator was not "treatment as usual" but "waitlist, simply laying down on a relaxing chair or bed, and non-specific relaxing activities (i.e. reading a newspaper)." Also the anxiety was a

secondary complaint, rather than a primary complaint. 7 1005 subjects (page 4 of Manzoni et al, 2008 review).

8 No information available on bias.

9 The reported effect size is Cohen's d.

Relaxation training in people with anxiety symptoms (in absence of depressive episode/disorder)

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Reference List

Carlson CR, Hoyle RH. (1993) Efficacy of abbreviated progressive muscle relaxation training: a quantitative review of behavioral medicine research. Journal of

Consulting and Clinical Psychology, 61:1059-67.

Eppley KR, Abrams AI, Shear J.(1989). Differential effects of relaxation techniques on trait anxiety: a meta-analysis. Journal of Clinical Psychology, 45:957-74.

Krisanaprakornkit T et al (2006). Meditation therapy for anxiety disorders. Cochrane Database of Systematic Reviews, (1):CD004998.

Manzoni GM et al (2008). Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC Psychiatry 8:41.

Stetter F, Kupper S. (2002). Autogenic training: a meta-analysis of clinical outcome studies. Applied Psychophysiology, 27:45-98.

From evidence to recommendations

Factor Explanation

Narrative summary of the

evidence base on the scoped

question

There is very low quality evidence favoring relaxation over no treatment in reducing anxiety

symptoms post treatment (N = 19; n = 1005; SMD = -0.51; 95% CI, -0.63 to -0.46).

Summary of the quality of

evidence on the scoped

question

VERY LOW (see GRADE table). A review summarizing a mixture of observational studies and

randomized trials was GRADEd.

Additional evidence (eg

related evidence that was not

scoped)

A Cochrane Review on meditation therapy for anxiety disorders (Krisanaprakornkit et al, 2006)

identified 2 RCTs for inclusion in its review of which 1 was on anxiety. Transcendental meditation

showed a reduction in anxiety symptoms and electromyography score comparable with

electromyography-biofeedback and relaxation therapy. The drop out rate was high (44%).

Relaxation training in people with anxiety symptoms (in absence of depressive episode/disorder)

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Balance of benefits versus

harms

Data on adverse effects were not meta-analyzed. The balance of benefits versus harms however

seems favourable.

Define the values and

preferences including any

variability and human rights

issues

The intervention is consistent with the value of promotion of capacity and skills of the person with

the illness/symptoms.

It is noted that many societies have their own culture-based forms of relaxation. These include

meditation - an intervention that also includes a cognitive component and is consistent with religion

and tradition in many areas of Asia.

It is noted that in low and middle income countries that the treatment of anxiety symptoms in non-

specialized health care settings is unlikely considered a priority public health decision makers and

health services staff.

Implementing these interventions may be done in group sessions (which may be more cost-

effective).

Define the costs and resource

use and any other relevant

feasibility issues

The administration of relaxation exercises is a relative non-sophisticated intervention that can be

quickly learned.

Relaxation tends to be a multiple session activity, which thus is costly in terms of human resource

use. Patients with anxiety symptoms often land up getting hypnotics - which have both resource

implications as well as the risk of dependence. The possible alternative of offering relaxation may

reduce the prescription of hypnotics.

Final recommendation(s)

In non-specialized health care settings, relaxation training should be considered as treatment for anxiety symptoms (in absence of depressive episode/disorder) - who are in distress or have some degree of impaired functioning. Strength of recommendation: STANDARD

Relaxation training in people with anxiety symptoms (in absence of depressive episode/disorder)

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Update of the literature search – June 2012

In June 2012 the literature search for this scoping question was updated. The following systematic reviews were found to be relevant without changing the

recommendation:

Halm MA. Relaxation: A Self-care Healing Modality Reduces Harmful Effects of Anxiety. American Journal of Critical Care 2009, 18( 2), doi:

10.4037/ajcc2009867

NICE National Clinical Guideline Number 123. Common Mental Health Disorders. National Institute for Health and Clinical Excellence, 2011

NICE National Clinical Guideline Number 113. Generalized Anxiety Disorders. National Institute for Health and Clinical Excellence, 2011